Tattoo Medical History Consent And Release Form printable pdf download

TATTOO

MEDICAL HISTORY CONSENT AND RELEASE FORM

Please circle YES or NO:

YES NO Diabetes

YES NO HIV

YES NO Heart Condition

YES NO Faintness or Dizzy Spells

YES NO Epilepsy

YES NO Hemophilia

YES NO Eczema/Psoriasis

YES NO Scarring/Keloiding

YES NO T.B.

YES NO Asthma

YES NO Herpes

YES NO Pregnant/Nursing

YES NO Hepatitis

YES NO Infections

YES NO Blood Thinners

YES NO Prophylactic Antibiotics

Do you have allergies? YES NO If yes, please list:_____________________________________________

Do you take medications? YES NO If yes, please list:__________________________________________

Are you currently under a doctor’s care for a continuing condition? YES NO

Are there any know medical problems that may affect you getting a tattoo? YES NO

When is the last time you ate? _____________________

Please Read:

•

This is to certify that I am at least 18 years of age.

I am not under the influence of alcohol or drugs.

•

I understand there is a possibility of an allergic reaction.

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I understand there is a possibility of an infection.

•

I understand that a tattoo is permanent.

•

I agree to allow for artist interpretation.

•

I understand that Fine Line Tattoo is not responsible for the interpretation of symbols and foreign languages.

•

I understand that Fine Line Tattoo does not guarantee any tattoo below the shoe line.

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I understand that Fine Line Tattoo does not guarantee any tattoo on the hand or fingers.

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I agree to follow all instructions given to me by Fine Line Tattoo and its employees concerning the aftercare of my tattoo.

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I understand that there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a tattoo.

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*If you feel this way during or after the procedure, please let us know immediately.

I understand there are NO REFUNDS.

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I’ve been given a chance to ask questions and they’ve been answered to my satisfaction.

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I hereby release Fine Line Tattoo & Body Piercing, LLC and its employees of all responsibility and liability for said tattoo.

Signature _______________________________________Print Name___________________________________

Address ________________________________City, State_____________________ Phone # _______________

D.L. #__________________Today’s Date ________________ D.O.B. ________________ Age _____________

Parent/legal guardian to fill out this section entirely:

If under 18, child AND parent/guardian signatures are to be done in the presence of a notary. Parent/guardian

_____________

must be present throughout the procedure and proper I.D. must be shown prior to service.

I, (print name)________________________________________ give permission for my child to receive a tattoo.

Parent/Guardian Signature _____________________________________ D.L. #________________________

Address_________________________________________ City, State ________________________________

Notary’s Statement:

Sworn and Scribed before me on this _______ Day of ______________ 20____.

Notary signature: ______________________________________________ Seal:

-------------------------------------------DO NOT WRITE BELOW THIS LINE-------------------------------------------

Design _______________________________ Placement _______________________ Artist ________________

Touch Up ____ New Tattoo ____ Repair ____ Cover ____ Outline Only ___ Black & Grey ___ Color ___

Care given: Verbally ____ Written ____

Time: Start ______________ Finish ____________

TATTOO

Tattoo Medical History Consent And Release Form

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